Through a large number of psychiatric emergencies (540 under age 18 in 2001), we explore the relation between the passage to the act and the emergency situation in adolescence: doesn’t modern psychiatry tend to define a psychiatry of the act ? The latter depends on internal causes at adolescence, but also on the environment. The work with these situations is then defined both by the constitution of an emergency service as an interior setting and by the development of an exterior network. The evolution of a ward for dealing with psychiatric emergencies in adolescence can thus be described.
The word “ contract ” in the title gives one to understand that there is a clear prior agreement, or at least a mutually accepted restriction; in other words, it suggests something definitive and under control. Attaching the qualifier “ treatment ” to it opens the way to the notion of therapeutic process with all that it connotes of psychical movement towards a future subject to ambivalence, to the pairing of idealization and de-idealization, to the contingent. The working process that has been engaged offers a therapeutic setting at once spatial and temporal which creates the conditions for the emergence of a transitional space. There is a fool’s bargain when the immediate normative aim takes precedence : – treatment by medicine alone- imposture of effective symptomatic treatment without any work of elaboration (which can lead to relapses and defensive psychical readjustments that allow the problem to evolve quietly with increasing risk) ; verification ; openness in information.
In France, The hospitalization of minors is governed by several legislative and statutory texts which emphasize that decisions about hospitalization and care belong to the holder of parental authority. However, they also assert the principle, in keeping with the international agreement concerning the rights of the child, of the necessity of the minor’s assent to care and the preservation, in specific cases, of medical confidentiality.
In France, for several years, special medical wards for adolescents have been created, whose targets are multiple : to evaluate the clinical situation, to contain the symptomatology, to bring an adapted answer and an appropriate treatment according to established diagnosis. This kind of ward, playing the part of substitute and containing agent, have to offer a transitional place in which the psychical workings of an adolescent will be able to spread, an adolescent who is looking for an external object it is possible to invest. Hospital staff meet with many difficulties (violence against others and oneself, work with the family, etc.) These wards have to define the treatment tool they represent and to their characteristics, their limits and their targets.
In a pediatric ward the absolute priority is to make room for potential entrants who present the specific somatic pathologies the ward is competent to deal with: the inevitable management of this flow necessitates hasty choices and decisions inconsistent with the slow tempo necessary to the organization of treatment in our discipline. However, though divergences in the temporality of treatment remain, the contrast between somaticians and “ psyche-ists ” tends not to be so pronounced once they are engaged in joint treatments on a daily basis. A certain softening of the pediatric culture championing short hospitalizations probably corresponds to the psychologist partners’ care in constructing acceptable arguments, in this sort of context, in defense of “ indications ” for prolonged hospital stays.
Through this work the author tries to identify parenting’s space of conflicts within the context of migration. He emphasizes the inter-and intra-generational aspects of these conflicts, as well as the absence of traces by which parents could enter into resonance with their children’s adolescence. He seeks to disengage these conflicts from the limited framework of the intrapsychical dimension, and to inscribe them in a larger framework, an interpersonal and interpsychical one that includes the impact of the professional and social environment. He proposes parents/adolescent therapeutic consultations, which are opened on the “ Network ” as an alternative in repairing the meshes of parenting and of parental functions.
Through the case of Wu-Ying, a psychotic teenager, we try to show what paths the psychical work can take. The choice of a transitional area composed of three people, associating a French teacher and a psycho-pedagogue – both clinical psychologists – and the company of an original literary work, Feather, by Henri Michaux, have allowed Wu-Ying to subjectivate his history, thanks to the dynamic play of passivation and drive activity.
The increasing number of requests for the institutional management of adolescents indicates either that adolescent crises have become more severe, or that the present forms of family organization render these families incompetent to manage the adolescents by themselves. This demand may be explained in part by the lack of procedures marking the passage to adulthood. Much adolescent behavior, in fact, re-enacts failed attempts at initiation rites. Work with adolescents can only be enriched and improved by knowledge of rites of passage practiced by traditional societies. The framework for containing violence and sexuality offered by these rites, the procedures for affiliation with the adult world which they implement, the re-elaboration of the symbolic which they impel, etc., make it possible to shed light on certain barriers that confront institutions for adolescents on a regular basis.
Using a case coming from an evaluation and several examples, the author discusses the difficulty of making interpretations to adolescents. The seriousness of the problems is more indicative of the adolescent processes taking place than of full-blown pathology. It requires the therapist to be rigorous and prudent in his interventions and interpretations.
At a time of technological changes, the contemporary adolescent fashions new modes of intersubjective organization (sms, chat, mail, networks, etc.) by producing multiple figures of his new reference points. The author invites the reader to follow the chaotic movement of this evolution, piecemeal, as suggested by this fragmentary mode that runs counter to the abecedary.
Adolescence, T. 31 n°1, pp. 235-238.
Revue semestrielle de psychanalyse, psychopathologie et sciences humaines, indexée AERES au listing PsycINFO publiée avec le concours du Centre National du Livre et de l’Université de Paris Diderot Paris 7